17
G. BACCHI ET AL.
that of isolated heart transplant recipients, according to
the UNOS database, this difference was not statistically
significant; several more recent studies from single
centres with a low number of cases have yielded en-
couraging results, both in terms of long-term graft
function and patient survival [4-7].
Moreover, in a recent analysis Russo et al [8], refer-
ring also to the UNOS database, found that low risk
patients with an estimated filtration rate of less than 33
mL/min gained a survival benefit from HKT over heart
transplantation alone.
In our experience with 7 patients who have under-
gone HKT with single donor allografts all patient are
alive at a mean follow-up of 45 months ± 24 months
(range, 75 months - 12 months) which supports the sat-
isfactory results of this procedure.
Some advantages can be noted in using the same do-
nor and a single operative session for both organs.
Firstly the recipients have a single exposure to alloan-
tigen avoiding further antigenic stimulation. Secondly,
they have a single induction immunosuppressive treat-
ment and, thirdly, when the surgical procedure is car-
ried out in the same surgical session they avoid a sub-
sequent anaesthesia and also the cold renal storage is
reduced. Some authors [6,9] have stated a preference
for a staged approach involving a later second operative
procedure. However, in the experience of kidney trans-
plantation, prolonged cold ischemic time (CIT) is a
well-known risk factor for delayed graft function [10]
which is itself associated to lower graft function and
graft survival rate in the long term [11].
In our experience, except for one staged procedure
which was necessary due to instable hemodynamic
conditions, all kidneys were immediately implanted
after the closure of the chest allowing for a CIT of no
longer than 10 hours.
Of note, many studies describe a low rate of rejection
in HKT [3,6,9] which is in accordance with another
recent analysis from UNOS clinical data [12] that
showed that both kidney and heart allograft rejections
are reduced when compared with each respective al-
lograft alone (17% vs 24%, p < 0.001 and 26% vs 52%,
p < 0.001; respectively). More generally they found that
the heart liver and kidney allografts are themselves
protected from rejection and that they protect the other
organ when transplanted from the same donor. It ap-
pears that any organ transplant combination may induce
tolerance or reduce host immunor esponsiveness, but the
mechanisms of this immune event in human patients are
not clearly understood even if various hypotheses have
been suggested [3,13,14].
In our study population, four out of seven patients
had no acute rejection episode of either organ and no
simultaneous rejection was noted. Despite the limited
data we have, this supports the fact that simultaneous
rejection is rare in HKT [15] thus suggesting that sur-
veillance of both organs is advisable and could be car-
ried out separately for each transplanted organ.
Despite the good clinical HKT results, the use for
two organs for one patient of such a scarcity of donors
may represent an ethical dilemma. We believe that this
issue can be at least partially settled with an optimal
candidate selection that is guided by the indications for
heart transplantation, viewing the combined kidney
transplant as a possibility to remove a contraindication
to heart transplant alone. Of note, as opposed to
end-stage kidney disease that can be artificially treated
with long-term dialysis, no mechanical device is cur-
rently represent a valuable option as a substitute for
heart transplantation for resolving end stage heart fail-
ure. Thus, heart transplantation may be the only life-
saving option in patients with end stage heart failure
that additionally suffer from end-stage kidney disease.
On the other hand, we do not believe that HKT should
be an option permitting kidney transplant in patients
with end-stage kidney disease and severe but non-
symptomatic heart disease, because heart transplant is
not proven to improve survival in these patients as
compared with optimal medical treatment for heart
failure [16]. Our current policy is to consider HKT in
patients with an indication for heart transplant, a low
comorbidity profile, and a creatinine clearance of less
than 30 mL/min due to parenchyma kidney disease [17],
(i.e. excluding patients with renal insufficiency secon-
dary to lo w-c ard iac ou tpu t alon e).
In conclusion, our results support the previously re-
ported data about HKT, suggesting that this procedure
has become a valuable option for selected patients
needing a heart transplant with concurrent severe renal
failure. Donor scarcity underlines the need for a careful
and stringent selection of candidate patients in order to
optimize the best outcome for both organs.
5. References
[1] J. Norman, D. Cooley, B., Kahan, et al., “Total Support
of the Circulation of a Patient with Post-Cardiotomy
Stone-Heart Syndrome by a Partial Artificial Heart
(ALVAD) for 5 Days Followed by Heart and Kidney
Transplantation,” Lancet, Vol. 1, No. 8074 , 1978, pp.
1125-1127. doi:10.1016/S0140-6736(78)90301-X
[2] S. Livesey, K. Rolles, R. Calne, J. Wallwork and T. A. H.
English, “Successful Simultaneous Heart and Kidney
Transplantation Using the Same Donor,” Clinical Trans-
plantation, Vol. 2, 1988, pp. 1-4.
[3] J. Narula, L. E. Bennett, T. DiSalvo, J. D. Hosenpud, M.
J. Semigran and G. W. Dec, “Outcomes in Recipients of
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